The Refundable Health Gain Premium (RHGP)
Summary
NHS services have evolved hitherto without the challenge of a pandemic. Covid-19 has exposed many fault lines within an historically unresponsive system. We have paid a terrible price. Previous grand plans for the NHS have clearly failed as judged by the outcome of the pandemic. Within the NHS, funding streams, organisational independence and political nervousness discourage collaboration and unity of purpose across stakeholders. I propose a new approach, The Refundable Health Gain Premium (RHGP), to unite and inspire us as we apply the post-pandemic lessons learned.
Introduction
Our NHS is orientated towards ill health rather than well-being. UK funding of healthcare is modest by top European standards. This proposal offers a radical new approach to promote change supported by financial incentives with an holistic appeal across all stakeholders. It is based on the well-tried axiom that ‘if enough people want something to happen at the same time it always happens’.
In essence, the proposal is to apply a novel, refundable, annual cash levy (RHGP) on all individuals and all organisations, public and private, that have a stake in maintaining and promoting good health. This would be a “top up” in addition to traditional taxpayer funding. Every premium could be fully or partially mitigated, if the individual or organisation is able to demonstrate delivery against agreed health gain standards set by NHS England in consultation. Failure to deliver mitigation would lead to the premium being non-returnable. Mitigation would result in a cost-in-kind health gain, based upon the changes driven by the performance achievements of individuals and organisations delivering a commensurate restraint upon funding requirements. Failure collectively to achieve mitigation standards would result in significant growth in funding sufficient to drive change and development centrally.
The annual RHGP for the population could be calibrated by the NHSE ambitions to achieve either cash, improved public health against targets, or a balance. Health Premiums and standards could be adjusted year on year as deemed appropriate by agreement between the Department of Health and Treasury.
The following would be subject to RHGP:-
1. Taxpayers- good health is positively connected to reduced stress, improved mental health, happiness, well-being, employability, and longevity. An individual would be subject to RHGP adjustments based on their unique health and financial circumstances. Those on benefits or low incomes would be exempt but encouraged to participate by the opportunity to receive a grant for achievement. An individual’s targets would be calculated considering delivery of relevant individual contributions to public health metrics. Data collection would be through the voluntary use of devices and Apps. The data would become a part of the annual online tax return with the outcome used to adjust tax codes by HMRC to retrieve any monies owed. Each year a random selection of individuals would go through a rigorous data check. Misrepresentation would negate any mitigation for a 1–3-year period.
2. Employers- a healthy workforce is less costly due to reduced sickness absence and improved productivity. All employers would be subject to RHGP according to size of workforce. The responsibility of the employer would be to provide a suitable, safe environment, facilities, supportive HR policies, encouragement around work/life balance and a child friendly approach. Added mitigation could be accorded for add on support around smoking cessation, weight control, provision of healthy eating opportunities, exercise etc.
3. Local Authorities- Social care provision seeks to maintain good health in its population. The RHGP would consider the extent to which the Authority had succeeded in achieving this overall objective using appropriate population markers.
4. Education- Schools, universities, and other relevant educational establishments have a responsibility to ensure children and young adults receive education within an environment in which they can develop and thrive. Regulator returns would include metrics on obesity, absenteeism, nature of and participation in exercise programmes, quality of nutrition offered, nature of pastoral care and learning directed towards healthy living. Any premium owing would be removed from local authority/central funding. For universities similar metrics could be used including mental health, drug use and extent of sexually transmitted diseases.
5. Industry- Industry will participate in RHGP as an employer. Some industries, such as food, alcohol and tobacco, that create and market products which are detrimental to health would have additional premiums based upon a separate set of appropriate metrics.
‘Gaming’ RHGP- Any system dependent on targets with penalties is liable to encourage gaming. On-line tax returns and annual accounts supported by the inspections from existing regulatory bodies would be available to detect gaming.
Conclusion
Here in the UK we have suffered perhaps the worst outcomes from Covid-19 of any nation. There will be an inquiry to understand how this happened. Other nations will do the same. A deeper, detailed understanding of how we need to shape healthcare in the future will emerge. It is unlikely to dent our enthusiasm for the NHS as our chosen vehicle for delivery. Centrally driven structural changes have not, and probably cannot, propel the NHS any further as rivalries and timidity at a political and organisational level obstruct transformational change. There lies the paradox. The NHS that already had a mixed reputation, that no other nation has chosen to introduce, that failed to protect us from Covid-19 must rise to this challenge.
A new approach, the Refundable Health Gain Premium is proposed. This will be levied against the delivery of specific, aligned objectives for individuals and schools, universities, businesses and social care and local authority establishments. Failure of mitigation in whole or in part, i.e. delivery against objectives in the field, would deliver increased funding to the NHS which could then be used to accelerate change through the traditional route of centrally driven initiatives.
This proposal drives health gain in a novel way yet within existing, familiar systems. Political support will be encouraged by maintaining the existing taxpayer funded arrangement within an NHS free at the point of delivery. It will become the responsibility of every citizen.
Mark Goldman
January 2021
1258-11